Steve Socransky – EDE Bloghttp://edeblog.com
EDE BlogThu, 10 Jan 2019 00:20:20 +0000en-UShourly1https://wordpress.org/?v=4.9.8Scanning the adnexa…a no-go zone?http://edeblog.com/2019/01/scanning-the-adnexa-a-no-go-zone/
http://edeblog.com/2019/01/scanning-the-adnexa-a-no-go-zone/#respondWed, 09 Jan 2019 21:35:15 +0000http://edeblog.com/?p=3879Since 2001, The EDE Course has been teaching Obstetrical EDE, both the abdominal and transvaginal approaches. Ever since then, participants have been counseled to simply evaluate for a definitive intrauterine pregnancy. If the answer to the binary question is yes, then an ectopic pregnancy has been effectively ruled out, unless one happens to be concerned about that rare heterotopic pregnancy in a certain subset. If no definitive intrauterine pregnancy can be declared, then the standard thing to do is to obtain an elective ultrasound, whenever that option happens to be available. If there are significant red flags or any signs of instability, then the suggestion is to consult gynecology prior to any consideration of discharge. You are also taught how to recognize the uterus and to make sure that any pregnancy seen is within it. Of course, if the pregnancy is outside the uterus, then it is likely in the adnexal area in the vast majority of cases. At the course, you are shown several examples of ectopic pregnancies. But you are not specifically shown how to scan the adnexa because this would be outside the scope of EDE. The upshot is that these ectopic pregnancies just showed up on the screen by happenstance, without specifically looking for them. However, not all ectopics will be seen by happenstance.

Those with Core IP certification can add an extra step to their routine and scan through the adnexal area in a methodical fashion. This will allow you to pick up a few more ectopic pregnancies earlier in their course and add an extra data point in your decision-making regarding the urgency of gynecology consultation, discharge, and any follow-up testing. How do you do that? Let’s use the transvaginal scan as an example. It is best to scan the adnexa in the coronal plane. Once you have swept through the uterus, go back to your best view of the uterus and then move the probe handle to the patient’s left or right. This will put the uterus to one side of the screen. Sweep the probe up and down while keeping your eyes focused on the area lateral to the uterus. Your sweep of this area should begin and end when the uterus disappears in either direction. After you scan the adnexal area to the right of the uterus, you should then move the probe in the other direction to scan the left adnexa in the same manner.

Here is a case example. A woman in her late 20s presented with lower abdominal cramping for three weeks. She was seen in an ED and had a positive hCG. A quantitative level was not available at the time. An Abdominal Obstetrical EDE was performed and an NDIUP was declared. The RUQ was negative for free fluid. The uterus was noted to be retroverted. No transvaginal scan was performed. An elective ultrasound was requested. It still had not occurred when she presented 3 days later, this time with mild vaginal bleeding. Past medical history included several prior pregnancies. She had one child. She had one STI remotely which was treated. There was uncertainty with respect to her last menstrual period, which was said to have occurred 1-2 months prior. Physical examination showed normal vital signs and only mild lower abdominal tenderness, which was maximal in the suprapubic area. Blood testing was not yet done. The uterus appeared empty on the abdominal scan. There was a suspicion of a small amount of free fluid. A transvaginal scan was then performed. The uterus was found to be empty. So the adnexal areas were scanned using the technique described above. Here is the first video with an attempt to scan the left adnexa. As you will see, the uterus is on screen left, with the adnexal area on screen right.

In the initial part of the above video, the probe was not moved sufficiently to see and scan the adnexal area well. So, the probe handle was moved further sideways in the last few seconds of the video to properly center the left adnexa on the screen. This next video shows the suspicious finding in the left adnexa fully centered on the screen and then swept.

See any free fluid? Fore sure. The naysayers will say that the finding of free fluid would have obviated the need to look for an ectopic mass. To be sure, free fluid alone would have made the Gyn consult automatic. But I have seen similar cases with an observed ectopic mass and no free fluid. So, an important data point.

Gyn assessed the patient and decided to go with Methotrexate. The patient did well with that treatment.

]]>http://edeblog.com/2019/01/scanning-the-adnexa-a-no-go-zone/feed/0Patients love imaging!http://edeblog.com/2018/11/patients-love-imaging/
http://edeblog.com/2018/11/patients-love-imaging/#respondWed, 07 Nov 2018 12:16:08 +0000http://edeblog.com/?p=3859A girl in her mid-teens presented with acute suprapubic pain that woke her that morning. It was described as a cramping or burning. It was persistent although not as severe at the time of physician assessment. In fact, it had become rather mild. There was no radiation. She had never had it before. Her last period was three weeks prior. There was no history of fever, nausea/vomiting, or any stool or urine changes. There was no discharge. The sexual/STD history was negative. Her past medical history was negative for any chronic diseases or surgery. She was not a smoker or drinker and did not use any drugs. On examination, she appeared to be in no distress and was not in visible discomfort at all. Her vital signs were normal with the exception of a heart rate of 112 at triage. When assessed by the physician, her heart rate had normalized. Her examination was normal with the exception of some very mild suprapubic tenderness. A pelvic examination was not performed due to the negative sexual history. Testing initiated at triage included a normal CBC and chemistries. Her urine was completely negative. Her pregnancy test was negative as well. Although the timing was not completely perfect, it sounded like a ruptured ovarian cyst to the treating physician. Given that the presentation otherwise had no red flags and that the examination was fairly benign, the physician planned to discharge the patient with the probable diagnosis of ruptured ovarian cyst and reassurance, along with over-the-counter pain medication as needed.

When the physician offered this explanation and plan to the patient and her parents, the parents were a little bit concerned that her pain could be so dramatic initially. They were concerned that something more sinister was at play. So, in order to reassure the parents, a bedside ultrasound was performed. Here is the pelvic scan in the transverse plane.

That was an ovarian cyst. It is a little bit involuted, which makes sense in the case of a rupture. You may have also noticed a thin rim of free fluid around the ovary and uterus. The free fluid prompted a scan of the RUQ.

Obvious free fluid in the RUQ. Did the POCUS result change the diagnosis and plan? No, not really. But it made the parents happier. There’s nothing like seeing an image that shows the diagnosis. Even better when you can show it to the patient’s parents

A blog post earlier this year from Lloyd Gordon presented a case of a hemorrhagic ovarian cyst. What is the difference between this case and that one? The clinical presentation, that’s it. Change the presentation and these scans could be entirely consistent with a hemorrhagic ovarian cyst in an unstable patient.

One last thing to add. We don’t specifically teach the diagnosis of ovarian cysts in any of the EDE courses. So if you are not sure of what you’re looking at, it is always prudent to get an elective ultrasound.

A 25 year-old man from the Caribbean had one month history of cough, low grade fevers and chest pain. He was seen 2 weeks prior with right-sided chest pain. A POCUS done at the time showed normal lung sliding. He presented via ambulance for the 2nd visit. Paramedics found a pulse of 109 and O2 Sat. of 96%. His BP was normal. His pulse settled to 90 with an O2 Sat. of 100% while in our ED. He had no particular risk factors for infectious diseases, no recent travel and was very physically active. Upon questioning he had used testosterone injections at the gym with clean equipment. Blood tests included a VBG which showed a mild respiratory acidosis, probably from splinting.

I thought he may have some sort of odd pneumonia, maybe TB? The exam was normal except that he was experiencing left lateral chest pain with movement and breathing. Two weeks ago it was on the right side. POCUS is of course better than a CXR in diagnosing pneumonia.

The pleura and lung POCUS was mostly normal.

The exception was some abnormal areas near the heart, liver and spleen. The really abnormal area was on the left lateral lower chest where he had the pain. [Ed note: that can make the scan more efficient. Place the probe where the pain is located. The yield will be higher.]

[Ed note: The last image points out that you can look for B lines and other abnormalities in the far field, in that wedge-shaped 6 to 9 o’clock area that is your area of interest on Pleural Effusion EDE (see red arrow)]

The IVC was normal. There was no evidence of RV strain.

I took a closer look at the left, lateral area with the linear probe.

Note the irregular pleura and areas of pleural effusion invaginating into the lung. This is typical of a Hampton’s Hump on POCUS.

Here’s the CXR which the radiologist said might be early consolidation.

It is likely that the parenteral androgen was the major risk factor for the PE. For more on that topic, click here.

So now you can diagnose PE at the bedside with lung POCUS. Click here for an article.

]]>http://edeblog.com/2018/10/lloyds-corner-unusual-lung-pocus/feed/0Cleanliness is next to…http://edeblog.com/2018/10/cleanliness-is-next-to/
http://edeblog.com/2018/10/cleanliness-is-next-to/#respondMon, 08 Oct 2018 03:12:37 +0000http://edeblog.com/?p=3828Every so often, we receive a question regarding endocavitary probe cleaning procedures. So I thought I would post some information regarding our process in Sudbury. In essence, you cannot go wrong if you use the same procedure as your radiology department.

Our cleaning process has been stable for many years. We involved different stakeholders in creating and adapting our policy. For instance, our ward aids are an integral part of the cleaning procedure. Many years ago, we asked Debbie, one of our ward aids, if she thought it would be best if we had our emergency physicians be the ones doing the cleaning. Here is a picture of Debbie when we asked her this question.

Can you tell from the look on her face what her response was? Right… So, we did not leave this to our emergency physicians. Here’s what we do.

When we need to use the endocavitary probe for a first trimester pregnancy case or a rule-out peritonsillar abscess case, we ask the ward aid to bring the probe to the patient’s room. The ward aid gets one of our 2 EC probes from a locked cabinet. The cabinet is an area of the ED where we are most likely to use the probe. Makes no sense to store the probe at the other end of the ED

He/she then documents the patient on which the probe is to be used, as well as the physician using it. Here is an image of one of our blank forms.

There is also a documentation sticker that goes in the nursing notes:

The emergency physician plugs the probe into the machine, prepares the probe appropriately, and performs the scan on the patient. Once completed, the nurse contacts the ward aid to have them disinfect the probe. The ward aid removes the sheath if not already done and then wipes the probe with an approved germicidal wipe. He/she then proceeds with the disinfection procedure using the device shown here. The device is in one of our dirty utility areas, the one closest to where we most commonly use the EC probe.

Once done, he/she completes the documentation of the cleaning procedure, places the probe back in its bucket, and locks it back in the cabinet.

And that’s it! If you have any questions or comments, feel free to post them.

]]>http://edeblog.com/2018/10/cleanliness-is-next-to/feed/0I’m afraid to do this…http://edeblog.com/2018/09/im-afraid-to-do-this/
http://edeblog.com/2018/09/im-afraid-to-do-this/#respondSat, 08 Sep 2018 17:05:09 +0000http://edeblog.com/?p=3815A young woman presented with four days of a sore throat. Her voice was muffled. She couldn’t open her mouth very wide. She had trouble swallowing her own spit. She had had strep throat a few times. She also had two episodes of peritonsillar abscess in the last two years, one of which required drainage. She was eating and drinking less due to the pain. She was also sore all over. Past history also included some substance abuse issues. Her vitals were normal except for a heart rate of 102. Physical examination revealed 2-finger trismus. There was swelling in the left tonsillar area. She had tender left tonsillar lymph nodes but there was no evidence of Ludwig’s angina. Here is her EDE/POCUS scan:

One of the reasons that we are posting this case is because abscess fluid in a peritonsillar abscess is usually black. But in this case, it is fairly isoechoic with the surrounding tonsillar tissue. This is less common. But can you see the difference in the echogenicity of the thick abscess fluid versus the tonsillar tissue? Towards the end of the video, we pressed down with the probe to confirm that the pus was jiggling a bit, to distinguish it from tonsillar tissue. Here is an image first without then with labels.

It looked like a sizable abscess so the decision was made to go ahead and drain it. The patient’s throat was sprayed up with lidocaine and we were able to drain 10 mL of pus, as shown in this image. As you can see, tape was placed around the proximal end of the needle to ensure not going too far.

Having had so much pus drained, the patient felt quite a bit better. She was given a dose of IV clindamycin and dexamethasone as well as IV fluids. She was discharged after a few hours of observation. She was seen the next day for another dose of IV clindamycin. She felt a bit better and the swelling was significantly improved. She was converted to PO clindamycin and did well thereafter. Given the recurrent nature of her presentations, an ENT referral was made.

As I like to point out at EDE 2, I only drained a peritonsillar abscess once during my training. It was during medical school with an ENT staff holding my hand. I went through five years of residency and a few years of practice in Sudbury before I attempted another one. Why? Because, like most people, I was afraid of hitting the carotid artery. But with bedside ultrasound, the procedure became not scary at all. In fact, it could be described as “idiot-proof”. As I pointed out in a post last year, most of the procedures that I have done for the first time have come after residency. POCUS is a big reason for that.

We have toyed with the idea for a while. What if we hold a contest and give away some cool POCUS stuff for free. POCUS is cool! Free is cool! POCUS and free together is super cool!! So that is what we decided to do. This summer we held a contest. The grand prize of a free EDE 1 or EDE 2 course would go to one medical student and one resident. All that participants had to do was follow us on Twitter or sign up on the blog. Here are the winners:

Donna Liao, MS3, UBC

Jennifer Evancio, R1, Family Medicine, Kamloops, UBC

Congrats to both! Donna with be taking the EDE course on Tuesday, September 25, and Jennifer will be taking EDE 2 on Wednesday, September 26. Both courses are taking place in Vancouver.

We had a huge response to the contest! So we have gave away a bunch of runner-up prizes. Ten residents and ten students won a copy of the book (print or eBook, their choice). Another 10 residents and 10 students won free access to the EDE 1 and 2 online modules. FYI, the EDE 1 modules are being re-developed using the cutting-edge, super cool and interactive EDE 2 format. They will be packaged together and make their debut sometime in 2019.

A women in her late 30s presented with a sudden onset of lower abdominal pain that started couple of hours before. She had some sort of ovarian surgery years ago. The LNMP was a week or two ago and she didn’t think she was pregnant. Hmmm…

The Head Nurse asked me to see the patient next as she was concerned about her. She seemed to be in pain but was calm, maybe a bit pale. Pulse 103. BP OK. Tender but not peritoneal.

After examining her I started by scanning for free fluid. Here is the RUQ:

And the LUQ:

Not that much, but positive. Onto the pelvis…

Free fluid more pronounced in the pelvis. The uterus was empty (not shown).

Pelvic views showed what I call a “Sturm and drang” appearance or colloquially a “mess”, blood clots and tissue…

The IVC was very narrow for a young, healthy woman.

She didn’t look too bad at that point so I ordered a 2 liter NS bolus and called Gyn and asked him to take her right to the OR.

A few minutes later the Nurses said she was having a seizure. At this point she was absolutely white. I ordered 2 units of uncrossmatched O- blood under pressure. Within a few minutes the O&G came. The B-HCG was negative but the treatment was the same: immediate laparoscopy! At surgery they removed a haemorrhagic ovarian cyst and a lot of blood from the pelvis and paracolic gutters.

So not an ectopic but in a young woman, a positive FAST and shock needs the same immediate treatment. The + EDE/POCUS gave me the confidence to ask the Gyn to take her right to the OR.

Editor’s note: There are barriers to doing POCUS on shift. One set of barriers falls into the cognitive category. What would have dissuaded us from not picking up the probe in a case like this? Patient in late 30s. Patient says she is not pregnant so why would POCUS be useful? Not hypotensive. Lots of lower abdo pain cases in this demographic…wasting time to scan all of them? Clues that you should pick up the probe: charge RN worried about patient. Significant pain. Tachycardia. Patient still has uterus. Maybe has ovarian abnormalities given prior ovarian surgery.

]]>http://edeblog.com/2018/08/lloyds-corner-ectopic-until-proven-otherwise/feed/0Winter is coming!http://edeblog.com/2018/07/winter-is-coming/
http://edeblog.com/2018/07/winter-is-coming/#commentsFri, 27 Jul 2018 03:26:13 +0000http://edeblog.com/?p=3787OK, winter is still far away. But it will unfortunately be here before you know it. Why do I mention that in the middle of a hot summer? Winter is hip fracture season. And hip fractures mean that it’s time to get your ultrasound machine, a needle, local anesthetic, and some other bits of gear to block the groin (i.e. femoral, etc.) nerves. There is growing evidence that doing so is beneficial to your patients. Some evidence that you can peruse at your leisure includes a Cochrane review and a meta-analysis published in CJEM. It is also a best practice in Ontario.

The femoral/fascia iliaca block is one of the nerve blocks that we teach at EDE 2, and is Greg’s chapter in the book. But the pickup among participants has been mixed. One reason for that is the timing of the course. If you take the course in April and only see your next hip fracture in December, your confidence in performing the block may not be sufficient to allow you to proceed.

Would it not be ideal to teach the femoral/fascia iliaca block right before hip fracture season? We basically tested that theory over the last couple of years in Sudbury. At the beginning of each of the last two winters, we put approximately ten of our emergency colleagues through the femoral nerve block workshop from EDE 2. Within a maximum of two months, ALL of them performed at least one of these blocks.

So we figured that if it’s good for the emerg docs in Sudbury, it must be good for emergency physicians elsewhere. With that idea in mind, we will be offering the same workshop in Toronto in late November. Each workshop will last 2 hours. Registration has been opened on the EDE 2 website for two 2-hour workshops on the morning of Thursday, November 29. There will be a workshop at 8 AM and then the same workshop will be repeated at 10:30 AM. If the workshops fill up, please sign up on the wait list. If enough folks sign up on the wait list, we will add workshops in the afternoon. Go to www.ede2course.com to register. See below for a screen grab of where the workshops are listed on the home page.

We started the EDE 2 course in February 2009. To be honest, myself and the rest of the team were still figuring out the best way to do the various scans that we taught. We were also improving our bedside teaching. As most of you know, the EDE courses place a heavy emphasis on image generation and deconstructing how that is best performed. It was sometime in 2010, over a year later, that I had the following experience. We were holding the course at a large venue. It may have been at EMU. In any case, I had to leave the stretcher that I was supervising for about 30 seconds to do something organizational. The participant that I was supervising was trying to do the A4C scan. I looked back at the participant, saw the screen, saw their hand, and I knew exactly what they needed to do to improve the image. So I said out loud to them so they could hear from a distance, “slide laterally and heel medially”. Immediately after I said that, a shiver went down my spine.

We had been trying to break the advanced cardiac scans into its component parts and probe movements and had finally figured it out about a year into the course. Being the tougher scan, A4C took a bit longer. It was at that course that everything came together to the point where our instructions could be purely verbal. Until then, we relied more heavily on holding the participant’s hand to guide them through a trouble area to help them through the scan. At first, it was because we didn’t know ourselves how exactly they should move the probe. Then, we didn’t know how to put it into words.… until that day. That shiver down my spine and the goosebumps that followed are what I call having reached the level of “EDE Zen”. By now, most EDE instructors have attained that level.

When you go from being a practitioner of POCUS to a teacher, the depth of your knowledge and skills must necessarily become more profound. This doesn’t happen overnight. Over this weekend, we held our first Nickel POCUS Bootcamp in Sudbury for the CPOCUS Resuscitation Track scans. Rob Lepage and Emily Conrad (photos below) were apprentice instructors. Rob is our ED Chief and Emily is one of our emergency medicine residents. Rob and Emily are already certified in the resuscitation track scans, but teaching is an entirely different story. When you first start teaching, it’s difficult to put into words the advice that you want to provide to a participant. And sometimes you’re not sure how they should move your hand based on what you see on the screen and the participant’s hand position. The only way to get around this as an new instructor is to place your hand on the hand of the participant and start moving the probe with them. If new instructors continue to teach POCUS, they will find the need to place their hand on the hand of the participant less and less often. One day, they may even surprise themselves with the instructions that they are able to put into words. And if you ever feel goosebumps right after you give those instructions, you have just had your first EDE Zen moment

P.S. Many thanks to Greg Hall and Julie Thorpe of Brantford for all the help and advice in getting this first Bootcamp in Sudbury off the ground. We couldn’t have done it without you!

]]>http://edeblog.com/2018/06/ede-zen-and-the-art-of-pocus-teaching/feed/0Incidental POCUS Findings – The Gallbladderhttp://edeblog.com/2018/06/incidental-pocus-findings-the-gallbladder/
http://edeblog.com/2018/06/incidental-pocus-findings-the-gallbladder/#respondMon, 04 Jun 2018 15:36:25 +0000http://edeblog.com/?p=3760There’s a whole host of abnormalities that one can find on POCUS. Some of them do not represent an acute problem. Most of them are of a minor nature and quite common, and do not need further imaging. But in a few cases, follow-up elective imaging is required. Here’s an example.

This elderly patient presented with near-syncope. A battery of tests was ordered at triage, including liver function tests. Most of these results were abnormal, showing a significant elevation compared to three months prior, when the LFTs were within normal limits. The patient was asymptomatic with respect to any gallbladder, liver or other biliary signs or symptoms. Due to the abnormal LFTs, a POCUS scan was done. This was the scan of the patient’s gallbladder.

What do you think? Is this sludge? It could be. But with sludge, you would prefer to see a fluid level/layer in order to confirm its liquid nature. The lumen of this gallbladder is almost completely filled with solid-looking material. It could be solid sludge. But this appearance should cause one to obtain elective imaging to rule out neoplasm. That was done in this case. The elective ultrasound and CT scan did confirm that this was solid sludge. But do not let this dissuade you from obtaining elective imaging to rule out a gallbladder tumour if you see something like this on the screen.